A Call to Consider Coercive Treatment
By Eriene-Heidi Sidhom
Approximately 50% of referrals to treatment programs come from the criminal justice system.^1,2^ 64% of those in residential programs and 57% of those in outpatient programs were involved to some extent in the criminal justice system, with 33% of those in residential programs and 42% of those in outpatient programs as a result of a direct referral. 2 The impetus driving court-ordered treatment is two-fold: first, 40% to 50% of crimes are committed by those using drugs or alcohol and 80% of people arrested for a crime are under the influence at the time of arrest; second, treatment is more cost effective than prosecution and incarceration. 3 However, these two reasons are not enough to justify the use of coercion, because they do not attest to the efficacy of treatment nor the correlation between treatment and reduction in crimes. Those who oppose coercion as an aspect of drug policy focus on the idea that clients are being forced into treatment against their will. 4 However, coercion should remain as an aspect of drug policy because the perceived coercion and motivation of the client does not correlated to the legal definition of coercion, and treatment for those who are “coerced” has been shown to be effective through measures, such as retention time. Therefore, coercion should not be eliminated entirely but should be implemented depending on different control variables, such as age and treatment environment, which have shown to be better predictors of treatment success.
History & Background
The idea of coercive treatment is not a new concept: as early as the 1700s, many psychiatrists recognized that self-harm might justify involuntary treatment. Despite the presence of this view in the scientific community, until the nineteenth century, addictive disorders were viewed as moral weakness rather than a medical condition and therefore were dealt with via punishment. In the mid-nineteenth century, people began to view addiction as a type of insanity, which resulted in funding for institutions for addicts. 5 Throughout the twentieth century, different types of coercive treatment centers emerged: first in the 1920s was the emergence of morphine maintenance clinics, followed by federal narcotics treatment facilities in Texas and Kentucky in the 1930s. The 1960s brought the first civil commitment procedures in New York and California. Finally, the current system was established in the 1970s which offers community-based treatment as an alternative to incarceration. 1
Although coercive treatment might be perceived as forced and involuntary, the formal definition of coercion is that the client is given a choice between accepting treatment or criminal sanctions. Compulsory treatment, however, is when the individual is forced to enter treatment. 3 Therefore, the criminal justice system operates on the belief that drug abusers will choose treatment over criminal sanctions. 3,5 However, legal coercion is not the only type of pressure. There are three forms of coercion: legal pressure, which involves the criminal justice system; formal pressure, which comes from employers or social assistance agencies; and informal, which comes from family members and friends. 3 Even within the criminal justice system, types of coercion can include a probation officer’s recommendation to enter treatment, a drug court’s offer between jail and treatment, or sending prison inmates into treatment programs. 1 The presence of pressure from outside the legal system is evidence that coercive treatment will occur with or without legal pressures, and the varying degrees of coercion within the legal system make it difficult to generalize the pressure felt by clients within the legal system. This variation necessitates more specific guidelines as to when coercion is appropriate.
Arguments For & Against Coercive Treatment
Opposition to coerced treatment is based on both philosophical and constitutional grounds, as well as on clinical grounds. According to medical ethics in American law, a person has a fundamental right to refuse treatment even at his or her own detriment or the detriment to others. 4 Furthermore, on clinical grounds, there is the belief that in order to benefit from treatment the client must be motivated. This point of view derives from the transtheoretical model for change which states that a person must progress through five stages in order to successfully achieve some behavioral change. According to this theory, motivation must precede the willingness to change and the ability to remain in treatment voluntarily. 3 Furthermore, in a study of 7,416 clients referred to treatment under California’s Substance Abuse & Crime Prevention Act (SACPA), perceived coercion was inversely correlated to motivation. 2 Therefore, those who oppose coercion believe that it is ethically wrong and that clinically it will be unsuccessful due to a lack of motivation. If the treatment is pursued despite predictions that it will be unsuccessful, it is a squandering of resources.
Those who oppose coercion base their argument on the assumption that individuals who are legally coerced into treatment perceive that they are there against their will. However, experimental data shows that perceived coercion and legal coercion are not equivalent. In a survey of 300 clients, 35% of those entering treatment under an external referral reported that they were not coerced, while 30% of those who were self-referred reported being coerced. 2 In a study of 157 people who entered a community-based drug treatment center, 57% entered as part of a court order, but nearly 40% of those said they felt no external pressure, while nearly 50% of the self-referred clients said they felt some form of external pressure. 6 The Drug Abuse Treatment Outcome Studies (DATOS) reported that 40% of those referred to treatment by the criminal justice system said they “think [they] would have entered treatment without the pressure of the criminal justice system”. 2,5 Despite the high numbers of referrals from the criminal justice system, there are still those within the system who have a desire to change, as highlighted in a survey of male prison inmates: 50% said they would be interested in a treatment program during the incarceration, and half of that group said they would even be willing to stay an extra three months. 2 This indicates that legal coercion does not necessarily translate into perceived coercion, and being referred by the criminal justice system does not indicate a lack of motivation or desire for change.
Effectiveness of treatment has been shown to be most strongly correlated to retention in treatment. 3 Despite worries that those coerced into treatment by the criminal justice system will have less success in treatment, there is experimental evidence to the contrary. In a study that grouped clients into four mutually exclusive groups (directly from prison, open cases, parole and/or probation or no legal involvement), those directly from prison were most likely to complete inpatient treatment. A similar finding was reported from another study of 100 substance abuse clients in a residential treatment center; the 42 involuntary admissions were more likely to complete treatment. 1 Additionally, in a study of 27,198 unique records on adult Texans with cannabis as the primary drug abuse problem, 69% were coerced into treatment. Those who were coerced were more likely to complete treatment (42%) as well as be abstinent from cannabis at the time of a follow-up interview (84%). 7 Experimental evidence continues to support positive treatment outcomes in clients who have been legally coerced, even when considering other measures of success. For example, court-ordered clients showed a similar drop in number of days involved in criminal activity (132 days to 35 days [71% reduction]) as the comparison group (61 days to 19 days [69% reduction]). There was also a significant decrease in average number of reported days consuming any drug, which dropped from 29 days to 12 days for the court-order group and 21 days to 15 days for the comparison group. 6 In a follow-up interview six months after a study that tracked 141 individuals from five outpatient programs in Ohio, participants in the coerced group were 2.8 times more likely to report no use of alcohol or other drugs in the thirty days before the interview. 8 Therefore, experimental data supports the efficacy of coercion as an element of drug policy when analyzed by a variety of measurements.
In addition to referral from the criminal justice system, other factors influence efficacy of treatment and thus should also be considered when determining whether coercion should be used. In a study of 7,416 clients, older age was more strongly correlated with completion of treatment, while the primary drug was not a predictor. 2 When investigating male residential clients, of which 38 entered voluntarily and 42 entered under various forms of legal pressures, dropout rates were most strongly correlated to age; younger clients who lived in one place for six months prior to entry into the program were more likely to leave within the first five weeks. 9 Type of treatment has also demonstrated correlation to completion. For example, those in residential treatment are 2.4 times more likely to complete treatment. 10 Furthermore, drug-free programs have been shown to be more strongly correlated to treatment success than methadone maintenance clinics. 1 Therefore, while coercion is an effective form of treatment, it can be made more effective by considering other success-determining factors such as age and treatment environments.
While those who oppose coercion as an aspect of drug policy cite a loss of autonomy and a lack of motivation in coerced patients, those referred under legal pressures still feel as if they are making their own choices and complete treatment at high rates and with higher rates of continued abstinence after treatment. It is therefore necessary to draw the distinction between coercion and perceived coercion. While coercion is a technical term that the legal system uses for giving the client the option between treatment or criminal sanctions, this does not always translate into the client feeling forced into treatment. In fact, many times, the client feels that they made the decision independently of the legal system. More importantly, individuals who are in treatment as a result of referrals from the criminal justice system have as successful, if not more successful, treatment outcomes as those who enter treatment voluntarily. Although the system is not perfect and there are still those who are involuntarily forced into treatment, that is the case with coercion outside of the legal system as well. Therefore, coercive treatment as an aspect of drug policy should be revised, rather than entirely eliminated.
1. Farabee, D., M. Prendergast, and MD Anglin. 1998. “The Effectiveness of Coerced Treatment for Drug-Abusing Offenders.” Federal Probation 62 (1): 3-10.
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